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The objective of this study was to review relevant research issues in the provision of culturally appropriate e-mental healthcare and make recommendations for expanding and prioritizing research efforts in this area. A workshop was convened by the Office of Rural Mental Health Research (ORMHR) at the National Institute of Mental Health (NIMH), the Center for Reducing Health Disparities at the University of California, Davis, the California Telemedicine and e-Health Center, and the California Endowment in December 2005, during which papers were presented concerning culture and e-mental health. Relevant literature was reviewed and research questions were developed. Major issues in the provision of culturally appropriate e-mental healthcare were defined, as were the barriers to the provision of such care in rural areas and interventions to overcome these barriers. Rural areas have increased barriers to culturally appropriate mental healthcare because of increased rates of poverty, increasingly large ethnic minority populations, and various degrees of geographical isolation and cultural factors specific to rural communities. Although culture and language are major barriers to receiving appropriate mental healthcare, including e-mental healthcare, they cannot be separated from other related influential variables, such as poverty and geography. Each of these critical issues must be taken into account when planning technologically enabled rural mental health services. This review describes one in a series of ORMHR/NIMH efforts aimed at stimulating research using culturally appropriate e-mental health strategies that address unique characteristics of various racial/ethnic groups, as well as rural and frontier populations.
The issue of how to deliver culturally appropriate mental healthcare has attracted national attention as more members of minority racial/ethnic groups are increasingly establishing residence in rural communities. For example, a recent United States Department of Agriculture report indicates that the Hispanic/Latino population in rural and frontier America has nearly doubled from 1.4 to 2.7 million, and is now the most rapidly growing segment of the population in nonmetropolitan counties.1 Culture is known to influence a number of aspects of an individual's healthcare, including approaches to advanced directives, preferences for differing treatments, and individual health beliefs, as well as attitudes toward autopsy, organ donations, and the disclosure of medical information.2 Also, a physician's cultural background may influence the interaction between themselves and a patient, potentially affecting patient access, use, treatment, quality, and outcomes.2
The delivery of culturally appropriate mental healthcare is particularly relevant in rural populations. Rural communities are burdened with limited access to mental healthcare specialty resources, never mind resources relevant to language or culture, which in itself can foster a culture of isolation. This cultural/geographical remoteness often creates a culture of fierce independence, which frequently manifests itself in grievances that are reflected in rural mental health literature.3 This includes angry protests/calls for greater support for increased mental healthcare resources (such as specialty services and parity in mental health reimbursement) and complaints about the relatively low quality of treatment received by rural people, which result in poor outcomes. As a response to these calls for additional mental health resources, and improved healthcare access, there have been a number of influential reports identifying information technology as potentially offering at least a partial solution.4,5 However, with the exception of Goal Six—“Technology Is Used to Access Mental Healthcare and Information”—in the President's Mental Health Report, there has been little time spent in these various reports considering how technology can help solve these problems.4
Unfortunately, little is known about how to deliver “culturally appropriate e-mental healthcare,” or even whether or not this is particularly different from the delivery of culturally appropriate mental healthcare delivered face-to-face in an office setting. Cultural differences may be more challenging during electronic consultations via videoconferencing, e-mail, or telephone, compared to face-to-face consultations. As the practice of e-mental health becomes more pervasive, it may be that managing cultural views and perspectives via technology will be even more important. To date, there has been a paucity of research concerning the provision of culturally appropriate mental healthcare, especially at a distance, and much of the completed research has been done with small samples and has employed weak experimental designs, with only a few exceptions.6–9
The goal of this paper is to review relevant research issues in the provision of culturally appropriate e-mental healthcare and make recommendations for expanding and prioritizing research efforts in this area. This work is an outgrowth of a National Institute of Mental Health (NIMH) workshop on e-mental health. The paper begins with a brief discussion of the workshop and defining “culturally appropriate” care, it then turns to a review and discussion of culturally appropriate e-mental care, and concludes with recommendations for future directions.
The impetus for this paper was a 2-day national workshop held at the University of California Davis in Sacramento, convened by the Office of Rural Mental Health Research at the NIMH, the Center for Reducing Health Disparities at the University of California, Davis, the California Telemedicine and e-Health Center, and the California Endowment in December 2005.
In this meeting, culturally appropriate care was defined as the delivery of mental health services that are guided by the cultural concerns of all racial or ethnic groups, including psychosocial background, typical styles of symptom presentation, immigration histories, and other cultural traditions, beliefs, and values. The 30 attendees included psychiatrists, psychologists, experts in information technology, telemedicine and cultural diversity, rural health researchers, and research methodologists from a variety of universities and health institutions in addition to UC Davis, including UCLA and the California Department of Health. The discussions of the attendees were focused on cultural aspects of three primary domains: Research, Training, and Healthcare issues. Technology and cultural experts presented papers on culture and e-mental health and examined barriers to delivering culturally appropriate e-mental healthcare in rural areas. At the conclusion of the workshop, recommendations for prioritizing and stimulating new research efforts in the area of culturally appropriate e-mental health were developed. Assignments were given to several groups of participants to work together to produce research review papers incorporating these ideas and recommendations. This is one of those papers.
Culturally appropriate care has been defined as “the delivery of mental health services that are responsive to the cultural and linguistic concerns of all racial or ethnic minority groups and non-minority groups, including their psychosocial issues, characteristic styles of problem presentation, family and immigration histories, traditions, beliefs and values.”10 There are many concepts that have been defined in the literature that underlie the potential achievement of cultural competence, often referred to as culturally appropriate/sensitive care or individualized personal care.11 These have been defined as the following:
These six broad conceptual areas of cultural differences are important to understand in the provision of mental health services in a cross-cultural perspective, and their importance is multiplied when one takes into account the influence of language, and the potential barriers that can be created if a patient and provider cannot meaningfully communicate with one another, or even understand the practical language of their interaction, not to mention the cultural underpinnings of their differences. It is evident from the breadth and depth of these cultural concepts that understanding them is essential for providers to be able to deliver high-quality face-to-face mental healthcare, never mind high-quality e-mental healthcare.
The above all-enveloping definition of cultural mental healthcare is difficult to achieve in rural areas, particularly where resources for the provision of all types of care are short. For example, it can be very difficult to access linguistic interpreting services in rural areas.12 Telemedicine could make such services more available and less expensive for smaller rural hospitals and clinics via telemedicine technologies. E-mental health represents a potential mechanism to move rural mental healthcare closer in line with the definition of culturally appropriate care.
Hundreds of articles have been written on the topic of mental health and illness among members of different ethnic groups, as well as strategies for delivering appropriate, competent cross-cultural mental healthcare,13–15 but very few are related to e-mental health. Regardless of whether care is provided face-to-face or using e-health technologies, it is important to be mindful of the potential ethnic and cultural differences in the prevalence of certain disorders.
The small but growing literature on e-mental health with diverse populations consists mainly of descriptive studies and case reports of work with prisoners, children, and minorities. Shore and colleagues have written a series of papers describing cultural issues in a series of clinics that use videoconferencing to provide ongoing mental healthcare for American Indian veterans residing in Western rural reservations.16–19 They also conducted a controlled trial of videoconferencing with this population demonstrating the diagnostic reliability of structured psychiatric assessments (Structured Clinical Interview for DSM-III-R), acceptability of videoconferencing within a cultural context, and the potential cost savings for using e-mental health for research with diverse rural populations.18,19*
Drawing on their experiences with these clinics as well as others, Shore et al. conducted a review of the impact of culture on telepsychiatry.20 Here they highlighted the key cultural issues that arose in their telepsychiatric experiences, and used the Outline for Cultural Formulation from the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) to frame principles for addressing these issues.20 Two components of the Cultural Formulation were particularly emphasized as relevant in telepsychiatry: (1) How a patient's cultural background (the cultural identity of the individual) influences his/her comfort with technology; and (2) The impact of cultural differences on the patient–provider relationship, specifically the need for the psychiatrist to attend to how culture-specific communication styles may impact the videoconferencing session. They noted that although advances in telecommunications technology have decreased disruptions to communication in e-health, verbal and nonverbal communication are altered somewhat in telepsychiatry versus an in-person meeting. The authors recommend that camera settings be adjusted to accommodate the communication preferences of a specific cultural group.20 Finally, Shore et al. noted that there are cultural differences between rural areas, where many e-mental health patients are located, and urban areas, where many e-mental health programs are found and made recommendations to address these differences.21
One way of thinking about the provision of effective and culturally appropriate e-mental healthcare is to examine the potential barriers that interfere with this delivery process. Barriers to developing an e-health program in general have been described elsewhere.21 The additional obstacles associated with developing a culturally appropriate e-mental health program are attitudes toward technology and the socioeconomic status of the population of interest.
While technology is certainly reported as being highly beneficial in enhancing mental health outcomes, actual access to information technology is extremely variable and such technologies themselves may also be viewed and understood differently by individuals of different ethnic and cultural backgrounds. The issue of disparate access to technology by individuals of different ethnic and cultural backgrounds reveals that access to information technology differs significantly, depending not only on an individual's race or ethnicity, but also their income, their education level, and their geographical location.22 African American and Hispanic/Latino individuals tend to report more affinity for information technology than whites do, but tended to have lower access to this type of technology, and poorer skills to use it effectively. When poverty and low socioeconomic status were taken into account, only the Hispanic/Latino group in Mossberger and colleagues' study22 actually had significantly poorer access to technology than the other two groups. Interestingly, these authors found that zip codes in areas of concentrated poverty were the most significant predictors of access to technology. The question then became, “Who lives in areas of concentrated poverty?” The answer is often ethnic minorities, and this appears to be true in both rural and urban areas. The conclusion of Mossberger and colleagues' research was that overall, concentrated poverty had a greater impact on technology access for African American populations than for white populations, but that they were not able to control for other factors signifying differences between urban and rural settings.
A parallel issue of cultural differences in interest in technology and its trappings has been demonstrated in cultural differences in the capacity to form online relationships. Despite little research being done on this issue, one study has shown that Asians, especially Koreans, were more likely to form online relationships than whites.23 Differences in affinity for using technology may have a number of different sources, including access, training, and socioeconomic variables that are not necessarily directly tied to an individual's cultural background. However, the circumstances faced by many ethnic minorities in the United States seem to set the stage for differences in interest in, attitudes toward, and experience with technology that will certainly influence the process of delivering quality e-mental health services. Shore et al. recommend a specific assessment of the impact of culture on an individual's willingness and comfort to engage in the use of technologies.20
Poverty seems, according to the literature, to be the most significant barrier to receiving culturally appropriate mental healthcare, whether in person or by telecommunications. Poverty not only affects the technology experience, often causing limited or complete lack of easy access, or access only via outdated technologies, but it also potentially adversely affects the experience of use as well as capacity to change healthcare outcomes. Community poverty is very common in rural areas; 14.2% of the nation's rural population is classified as poor, compared to 12.5% of the general population nationally.24 Indeed, 81 nonmetropolitan counties in the United States have poverty rates above 30%, and 12 have rates above 40%, with Tulare County in California noted as the most impoverished county in the nation. These rates of poverty are magnified among rural ethnic minority groups, which on average suffer double the rate of poverty of their counterpart white rural populations. Rural white populations report poverty in 11% of their members, compared with rural African Americans (33%), rural Native Americans (30%), and rural Hispanic/Latinos (27%). Rural areas are known to spend less per capita on mental health than their urban counterparts, and thus, are less likely to support a mental health practice and less likely to attract and retain mental health specialists.25 Individual and family poverty also has been well described as a predictor of poor mental health utilization and health outcomes and reduced overall quality of mental healthcare.
Another major confounder across many of these studies is education level, which tends to be related to poverty, as well as to socioeconomic status, and which may be related to decreased use of appropriate mental health services. An individual's educational background may also be correlated with previous exposure to technology, which could in turn impact their comfort and openness to engage in e-mental healthcare. Although Shore et al. discuss this hypothesis, to our knowledge it has not been rigorously assessed.20 It is also important to keep in mind that there are differences between structural or community-level poverty and individual or family poverty. It is possible for there to be a disconnect between the economic standard of a specific community or cultural group and the economic standard of a particular individual or family who belongs to that community.
It is clear from this review that there is a substantial need for more concerted research on intersecting issues of culture, language, social class, ethnicity, geography, and e-mental health. There are a number of scientific and policy questions that arise from this review. These include the following:
These are questions and research issues of critical importance. As globalization increases, the concept of providing quality, culturally appropriate mental health services will continue to become more important. E-health technologies appear to be uniquely suited to providing such services, but additional attention is needed from an e-mental health research and policy perspective. Using e-health to provide culturally appropriate mental health services is likely to require substantially increased funding from Federal and State levels and private payers, as well as an interest from the scientific and mental healthcare services community, but certainly seems an essential endeavor as the cultural diversity of our population rapidly increases.
*Shore JH, Savin D, Orton H, Grigsby J, Manson SM. Acceptability of telepsychiatry in American Indian veterans (unpublished).
The authors wish to thank the UC Davis Health System for hosting the workshop on Cultural Appropriateness in e-Mental Health, December 2005, and acknowledge the contributions of the California Telemedicine and e-Health Center and the UC Davis Center for Reducing Healthcare Disparities to the workshop. The authors also wish to thank Anthony Pollitt, Ph.D., for his reviews and comment on a draft. This work was funded in part by the Office of Rural Mental Health Research at the National Institute of Mental Health.